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What nursing order should be included in Mr. Puff’s care plan?
- A. Increase fluid intake to a minimum of 3000 ml/day
- B. Provide for postural drainage for 20 minutes after meals
- C. Restrict visitors
- D. Walk in hall t.i.d. for 20 minutes
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Why should a nurse use affective touching cautiously?
- A. It may lead to misunderstandings or discomfort.
- B. It involves the contact required for nursing procedures.
- C. It is used therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What controls the cyclic changes between waking and sleep?
- A. Fluctuating levels of melatonin
- B. The environmental light-dark cycles
- C. Key nuclei in the brainstem, hypothalamus, and thalamus
- D. A variety of neuropeptides released from the nervous system
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?
- A. The client rates pain as 5/10 at the site of the procedure.
- B. A small amount of drainage is noted from the site.
- C. Pulse oximetry reads 93% on 2 liters of oxygen.
- D. The trachea is deviated toward the opposite side of the neck.
Correct Answer: D
Rationale: The correct answer is D because tracheal deviation indicates a potential tension pneumothorax, a life-threatening emergency requiring immediate intervention. Tracheal deviation occurs when there is a significant shift in the mediastinum due to increased pressure in the pleural space. This can compromise respiratory function and lead to respiratory failure. Options A, B, and C are not as urgent as tracheal deviation. Pain at 5/10 is expected post-thoracentesis, a small amount of drainage is common, and a pulse oximetry reading of 93% on low oxygen is concerning but not immediately life-threatening.
When teaching a client with chronic obstructive pulmonary disease (COPD) about nutrition, what information should be included? (Select all that apply)
- A. Avoid drinking fluids just before and during meals.
- B. Rest before meals if experiencing dyspnea.
- C. Have about six small meals a day.
- D. Eat high-fiber foods to promote gastric emptying.
Correct Answer: D
Rationale: The correct answer is D: Eat high-fiber foods to promote gastric emptying. In COPD, patients may experience slow gastric emptying due to decreased lung function. High-fiber foods can help with digestion and prevent constipation.
A: Avoid drinking fluids just before and during meals - Incorrect. Hydration is important for COPD patients, but timing of fluid intake is not directly related to nutrition in this context.
B: Rest before meals if experiencing dyspnea - Incorrect. While resting before meals can help with dyspnea, it is not directly related to nutrition education.
C: Have about six small meals a day - Incorrect. While small frequent meals may be beneficial for some COPD patients, this is not a universal recommendation for all individuals with COPD in terms of nutrition.
A client takes atorvastatin (Lipitor), with laboratory results showing a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?
- A. Ask if the client eats grapefruit.
- B. Assess the client for dehydration.
- C. Facilitate admission to the hospital.
- D. Obtain a random urinalysis.
Correct Answer: A
Rationale: The correct answer is A: Ask if the client eats grapefruit. Atorvastatin can interact with grapefruit juice, leading to increased drug levels and potential toxicity. The elevated BUN and creatinine levels suggest possible kidney impairment, which could be exacerbated by the drug interaction. Assessing for grapefruit consumption allows the nurse to address this potential risk factor.
B: Assessing for dehydration would not directly address the potential drug interaction with grapefruit.
C: Hospital admission is not necessary based solely on the information provided; this would be an extreme action without further assessment.
D: Obtaining a random urinalysis would not provide relevant information related to the potential drug interaction with grapefruit.